Form Dsmv 505 - Release Of Motor Vehicle Records - Division Of Motor Vehicles - Nh Department Of Safety
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1
2RELEASE OF
NH DEPARTMENT OF SAFETY
Division of Motor Vehicles
MOTOR VEHICLE
23 Hazen Drive, Concord, NH 03305
RECORDS
Telephone: Driver Records/Accidents
(603) 227-4040
Registration
(603) 227-4030
Title
(603) 227-4150
Fax
(603) 271-1061 (all areas)
(Pursuant to RSA 260:14)
Form DSMV 505
(Rev. 09/12)
I. Requested Information:
II. Requestor Information:
Are you requesting:
Your Motor Vehicle Record?
: ____________________________________________________
.
Name of Requestor
A
Another person’s Motor Vehicle
B.
Suburban Propane LP and its subsidiaries and affiliates
Record?
Employer/Company
: _______________________________________________
(If applicable)
The back of this form must be completed and notarized.
240 Route 10 West
Another person’s Motor Vehicle
Address: ________________________________________Tele.#: ___________________
C.
Record as an authorized agent of
your employer or a company?
Whippany
NJ
07981
City: ___________________________________ State: __________ Zip: ______________
A Certificate of Authority must accompany this request, or one
must be on file with the Division of Motor Vehicles.
III. Requested Records:
IV. Intended Use of Information:
IMPORTANT:
To be completed only if you checked Box C above
Driver Record (Certified copy):
$ 15.00
For use in connection with any civil, criminal, administrative or arbitral proceeding.
Driver Record (Non-Certified copy):
$ 15.00
Docket # _____________________ Court: ____________________[RSA 260:14 V (a)(2)].
Driver Record (Insurance copy):
$ 15.00
By a bank or similar institution to verify the accuracy of personal information submitted by
the individual to the bank [RSA 260:14 V (a)(3)].
Registration Listing (Current Information Only): $ 5.00
For providing notice to the owner(s) of a towed or impounded vehicle [RSA 260:14 V (a)(5)].
Registration (Certified copy):
$ 15.00
For use by any private investigative agency or security service licensed by this state for any
purpose permitted pursuant to RSA 260:14, V (a), other than for bulk distribution for
Title (Certified copy):
$ 15.00
surveys,
marketing
or
solicitations
pursuant
to
RSA
260:14,V(a)(8)
__________________________ [RSA 260:14V(a)(6)].
Title Search (not a duplicate title):
$ 20.00
Indicate specific reason here
License Applications and Letters of Verification: $ 15.00
By an employer or its agent or insurer to obtain or verify information relating to a holder of a
commercial driver’s license [RSA 260:14 V (a)(7)].
Insurance Card (Accident use only):
$ 1.00
By a public utility to perform its public service obligation provided the individual has given
their express consent [RSA 260:14, V (a)(9)].
Storage/Mechanics Lien (RSA 444:4-a):
$ 0.00
For an insurance company or by its authorized agent [RSA 260:14 IV (a)(2)].
Accident Report
(Requestor will be notified of cost):
$ 1.00 per page ($5.00 minimum)
Vehicle or boat information only.
Other: _______________________________: $______
For use by a life insurance company authorized to write life insurance policies in New
Hampshire, or its authorized agent. In checking off this box, I represent that the named
person’s written consent to the release of the record has been obtained and that the
Make checks payable to “State of NH – DMV”
record will be used solely in connection with claims investigation, rating, and
underwriting. ________________ [(RSA 260:14, V(a)(10)]
(Initial here)
V. Search For (provide all applicable information):
Last Known Address: ________________________________
Name:____________________________________________
__________________________________________________
Date of Birth: ______________________________________
Date of Accident: ____________________________________
Registration/Plate #: ________________________________
Location of Accident: __
_______________________________
Driver License/I.D. #: ________________________________
Route/Street
City/Town
Vehicle Identification #
______________________________
:
Other Identification Information:
____________________________________
***Reverse Side Must Be Completed Before Processing***
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